Frontier Community Healthcare Network Coordination Grant

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8 Grantee Data Collection Form	Form and Instruction	Unchanged	Available
Form 7 Client Interview/ Focus Group Protocol	Form and Instruction	Unchanged	Available
Form 6 Grantee Interview Protocol	Form and Instruction	Unchanged	Available
Form 5 Care Transitions Coordinator Interview Protocol	Form and Instruction	Unchanged	Available
Form 4 Community Health Worker Interview Protocol	Form and Instruction	Unchanged	Available
Form 3 Primary Care Provider Interview Protocol	Form and Instruction	Unchanged	Available
Form 2 Hospital Administrator Interview Protocol	Form and Instruction	Unchanged	Available
Form 1 Client Satisfaction Survey	Form and Instruction	Unchanged	Available
Appendix B1 CHW Data Collection Form -Client Data.docx	Supplementary Document	Uploaded 2014-03-20	Available
Appendix B2 CHW Data Collection Form-Design Implementation Data.docx	Supplementary Document	Uploaded 2014-03-20	Available
Appendix B5 CHW Data Collection_Technical Assistance Training.pptx	Supplementary Document	Uploaded 2014-03-20	Available
Appendix B4 CHW Data Collection Form- Excel.xlsx	Supplementary Document	Uploaded 2014-03-20	Available
Appendix B3 CHW Data Collection Form- Help.docx	Supplementary Document	Uploaded 2014-03-20	Available
Appendix A Site Visit Materials.docx	Supplementary Document	Uploaded 2014-03-20	Available
Supporting Statement B.docx	Supporting Statement B	Uploaded 2014-03-20	Available
Supporting Statement.docx	Supporting Statement A	Uploaded 2014-05-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209805	Grantee Data Collection Form	Form and Instruction	Unchanged	Grantee Data Collection Form
209804	Client Interview/ Focus Group Protocol	Form and Instruction	Unchanged	Client Interview/ Focus Group Protocol
209803	Grantee Interview Protocol	Form and Instruction	Unchanged	Grantee Interview Protocol
209802	Care Transitions Coordinator Interview Protocol	Form and Instruction	Unchanged	Care Transitions Coordinator Interview Protocol
209801	Community Health Worker Interview Protocol	Form and Instruction	Unchanged	Community Health Worker Interview Protocol
209800	Primary Care provider Interview Protocol	Form and Instruction	Unchanged	Primary Care Provider Interview Protocol
209799	Hospital Administrator Interview Protocol	Form and Instruction	Unchanged	Hospital Administrator Interview Protocol
209798	Client Satisfaction Survey	Form and Instruction	Unchanged	Client Satisfaction Survey

ICR Details

OMB Control No: 0915-0383	ICR Reference No: 201403-0915-005
Status: Historical Active	Previous ICR Reference No: 201312-0915-006
Agency/Subagency: HHS/HSA	Agency Tracking No: 21066
Title: Frontier Community Healthcare Network Coordination Grant
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/03/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved
Responses	209	0	0
Time Burden (Hours)	236	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: As part of the Montana FCHCNC Grant's review, we will conduct site visits and telephonic interviews with the critical access hospitals, tertiary hospitals, support staff and clients. We will collect data quarterly from the grantee sites and utilize cost data to assess cost effectiveness. Data collection will focus on patient/family satisfaction, whether goals were achieved in working with patients, and the strengths and challenges associated with implementing the program.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 54662	09/05/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 76310	12/17/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Care Transitions Coordinator Interview Protocol	5	Care Transitions Coordinator Interview Protocol
Client Interview/ Focus Group Protocol	7	Client Interview/ Focus Group Protocol
Client Satisfaction Survey	1	Client Satisfaction Survey
Community Health Worker Interview Protocol	4	Community Health Worker Interview Protocol
Grantee Data Collection Form	8	Grantee Data Collection Form
Grantee Interview Protocol	6	Grantee Interview Protocol
Hospital Administrator Interview Protocol	2	Hospital Administrator Interview Protocol
Primary Care provider Interview Protocol	3	Primary Care Provider Interview Protocol

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	209	0	0	209	0	0
Annual Time Burden (Hours)	236	0	0	236	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information request.

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Annual Cost to Federal Government: $166,506

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/28/2014

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